Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a
doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from our readers and the question was
My Mother is in the ICU for Cardiac Arrest. Are These Anti-Seizure Medications (Phenobarbital) Keeping Her Asleep Much Longer?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Stephanie as part of my 1:1 consulting and advocacy service! Stephanie’s mother is
on post-cardiac arrest care in the ICU, and is asking if there is a way for her mom to wake up real soon and be oriented?
My Mother is in the ICU for a Cardiac Arrest. How Soon Will She Be Oriented and Extubated?
Patrik: You know, I mean, how much easier is it to go to rehab without a trach, as opposed-
George: Correct-
Patrik: -to go to LTAC, which is a huge delay.
Stephanie: Yes.
Miranda: Y’all, great big dollar signs, that’s what the trach is about. The dollar signs.
Patrik: Oh, absolutely. It’s all about the dollar there. You know-
Right. It’s all about the dollar. And it’s about the base, it’s about the ICU resources.
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Stephanie: That’s right.
Patrik: And again, don’t get me wrong, there is a time and a place for a trach.
But, before you sign, before you do a trach, you need to tick all the boxes, you know, if she can’t be weaned off the ventilator, you know, she has an un… you know, there are certain boxes to be ticked, which then leads me to the next question, what are the benefits of a tracheostomy pros and cons, you know.
The pros are definitely that patient- a tracheostomy is not uncomfortable. You know, you can see the breathing tube would be very uncomfortable. A tracheostomy is very comfortable. It’s not painful, you know, and people can be weaned off in their own time, whereas with
the breathing tube, as you can already see, there’s, you know, you sort of need to hurry up with the breathing tube. With the tracheostomy, you have a lot of time.
And a lot of time, it’s good, if you are in the right environment. If you are in ICU with a trach, I have no concerns. But if you leave ICU and go to LTAC with a trach, I have massive concerns.
George: Correct.
Tonette: Mm-hmm (affirmative)-
Stephanie: So then, what can we do to make sure that they don’t do that? You know, what kind of policy we have, what kind of, you know…support do we have?
And patient advocacy do we have, to make sure that that doesn’t happen.
Patrik: Yeah, exactly, exactly, so the first thing is, one of you would be the medical power of attorney and you would have to sign off on a trach, right?
Stephanie: That’s Miranda.
Patrik: So, number one, you don’t have to sign off. You know, you can tick all the boxes in terms of, you know, I wanna make sure I, you know, the first thing then, the first thing that I can see needs to happen is, they need to stop the Phenobarbital and try and wake her up. That’s the next thing that needs
to happen.
You know, because, once she’s more awake, chances that she can come off the ventilator are much higher.
Tonette: Yeah.
Patrik: Right? So, and you see, people come to us all the time and they say, “Oh, they’re putting pressure on us, you know, we need to consent for a trach, or we need to consent for this, for that”-
Rebecca: No.
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Patrik: And I just say like, “So what?”. Nobody can force you to do anything.
Stephanie: Right.
Rebecca: Well that’s what they’re doing. I’ve been there. That’s what they’re attempting to do, and I told them, because I wasn’t in agreement with Dr. Reynolds, he, that’s what he wants to do. He wants to do the rush job, and that’s that’s not gonna happen.
Patrik: No, it’s not going to happen. And that’s the right mindset to have. A lot of it will come down to your mindset. A lot of it comes down, you know, you’re just responding to an outside event. That’s all it is. You can’t control other people, but you are 100% in control in how you respond. You are 100% in control.
Right? There is no law in this world that can force you to consent to a tracheostomy unless they’ve tried all the other things.
Miranda: Excuse me, let me interject this right now with what the doctor said. It appears to me, that that’s the direction that they’re moving in, and also, I spoke to Dr. Reynolds today, and they were talking about how they have a resident there, they have a PA, and they have another person, as opposed to one doctor if she goes off her, to the LTAC unit. And I said, “No, it would be better if she had three.”
Okay, even though Dr. Reynolds is a residential student, and he still has more time, when I see residents I thinking about, “You’re still in training. That you haven’t fully completed.” But he says that they have. That’s what I wanted to say.
Patrik: Very much so, very much- but I can tell you, in Carmen’s current condition, she won’t be going anywhere. She’s not going anywhere with the Phenobarbital on board. She’s not going anywhere. Right?
I do believe you have a relatively large time window because she’s still on the Phenobarbital and it will take her time to come out of that. So, from that perspective, now that I have that information, I do actually think you have way more time than I initially thought. I can tell you she’s not going anywhere on the Phenobarbital.
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Miranda: So why would they be trying to, they keep saying, “Oh, she’s not reacting.” But why would she be reacting if she’s on something that strong. That don’t make sense.
George: Exactly.
Patrik: Say that again, please? Can you speak up a bit?
Miranda: Say what again?
Stephanie: Speak strong. Yeah, you gonna make yourself speak strong. Go ahead.
Miranda: I’m in the hospital. I’m inside.
Stephanie: Okay, gotcha. Okay, yes. So why would they keep saying that her condition and her responses are still the same, oh she’s about the same, she’s about the same. You know, why should she react? She’s not reacting, they said.
Of course, why should she react when she’s on so strong meds?
Patrik: Correct. That’s right. Her condition wouldn’t have changed in the last few days, because as long as she’s on the Phenobarbital, that’s completely knocking her out. Right?
Of course, her condition wouldn’t be changing. What I would be worried about though, is, do a degree, it’s good that they’re saying her condition isn’t changing because it means her heart is stable, right, and that’s certainly a concern after a cardiac arrest, right. But if her heart-
Rebecca: They said it was stable.
Patrik: Right. That’s positive, that’s positive. The heart, at least from what I hear from you, the heart doesn’t seem to be so much a concern at the moment. The neurological condition is a concern.
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Rebecca: Absolutely.
Miranda: It sound like everything has something to do with this brain. That’s what I’m getting-
Patrik: Right, right, right, absolutely, absolutely, so that’s why, you know, the whole neurology input is going to be really important.
Patrik: Do you know, is she on any pressors? Do you know what I mean by that? Vasopressors?
Stephanie: Yes.
Patrik: She is?
Stephanie: No, no, any kind of pressors, you mean like V-pack, Vipack? No?
Patrik: No, no. No, no, vasopressors are something different. Vasopressors means, it’s given for low blood pressure, which could be a sign that the heart-
Tonette: Yes-
Patrik: Do you know whether she’s on that?
Tonette: Yes
Patrik: She is?
Tonette: They have her on, let me explain that. They have the ports in. The central line that give access to two, it leads to arterials, the arterial line as well as another line, and it’s a third entry if they need it for something else. But they’re using that because the Phenobarbital won’t drop the blood pressure so low, hypo-
Patrik: Yeah, yeah, yeah, yeah.
Rebecca: Right.
Tonette: They’re using that to try to keep her baseline pretty good. So her mean, the mean of her blood pressure, last I remember was around 68 or 70. Is that what it’s showing now, Miranda?
Patrik: Yeah.
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Miranda: I mean, let me walk back to it.
Patrik: Yeah. So it needs to be above 65, and I know, that, and that’s what I’m saying the Phenobarbital is completely knocking her out which means, you know, she needs the pressors for a physiological blood pressure. But again, to a degree, that information-
Miranda: She’s at 73.
Patrik: Right, right. That information, to me, is also another sign, she’s not going to LTAC any time soon. Because they couldn’t manage that in the
LTAC.
Tonette: Okay.
Patrik: Right? So from that perspective, you have a little bit of time, by the same token, they need to stop that Phenobarbital. You know, that is just to me, like, there would have been other ways to manage that as far as my experience shows. The Phenobarbital is, from my perspective, a last resort drug.
And I’m not sure, maybe you know that. Do you know whether they used Midazolam or Versed to manage the seizure? Do you know that?
Tonette: Midazolam?
Patrik: Yup, or, also known as Versed.
Miranda: Michael Jackson had that.
Patrik: No, Michael Jackson had Propofol.
Rebecca: I’m sorry I didn’t hear you. I got some information. I took some notes.
Means that Midazolam or what else?
Patrik: Midazolam also known as Versed.
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Rebecca: I don’t know.
Patrik: You don’t know, okay. Because that from my perspective would have been a safer option to manage the seizures, without using the Phenobarbital.
Tonette: Yes, okay.
Patrik: Okay, so. Go on.
Rebecca: Let me say this, the neurologist is the one who ordered the Phenobarbital.
Patrik: Oh yeah, would have been, would have been, yeah.
Rebecca: Yes. Mm-hmm (affirmative)-got it, go ahead.
Patrik: So now, you’re asking, “How can you be sure they’re doing everything they can for Carmen?”
Now, to this point, as far as I can see, they’ve done the stent, they’ve put her in an induced coma, you know, then they will…realising she’s having seizures, she’s having the jerking, they’re giving her Propofol and the Fentanyl That didn’t work, that wasn’t enough. They started the Phenobarbital.
I, you know, from my perspective, yes, they’re doing all the right things. From my experience, they shouldn’t give the Phenobarbital. They should’ve tried the Midazolam and Versed first, because that’s not quite as powerful, it’s still powerful, but not quite as powerful as the Phenobarbital.
Because my concern is, you know, somebody with a neurological event, you want to assess them whether they can wake up or not as quickly as possible. The Phenobarbital is dampening any response.
Stephanie: Exactly.
Patrik: Right?
Stephanie: It’s amazing that they have any response at all even with that.
Patrik: Right, right. She may be on a low dose, she may be on a low dose.
Hopefully. Hopefully.
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Miranda: I can ask.
Patrik: Yeah.
Miranda: I’m right here.
Patrik: Sure, sure.
Miranda: But I do have a question. What they were saying was the reason they had put her on that was basically what I’m understanding, she still in an underlying issue with the tremors or something like that.
Tonette: Mm-hmm (affirmative)-
Patrik: Underlying?
Miranda: There was a name.
Patrik: Underlying issue?
Miranda: I don’t know if they fully controlled … Stephanie, what’s the correct name that I heard you say the other day?
Stephanie: The tremor. The trembling, the myoclonic, the jerking.
Miranda: There we go, myoclonic-
Patrik: Myoclonic jerking. Myoclonic jerking.
Stephanie: Yeah.
Miranda: They say that even though she was on the EEG, it seems like there’s still some signals that she’s still having it. Having those.
Stephanie: When they try to pull it, pull whatever medicines they’re saying, then she started having those more. So they say there’s some type of damage to the brain. Not damage, but some kind of abnormal brain activity.
Miranda: Every time, they’ve only tried to pull it one time, from what I know.
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Stephanie: That’s true.
Miranda: And then the second things was their EEG machine went down, and they put her back on Prololol.
Tonette: Propofol.
Patrik: Right, right.
Stephanie: And also, they did not have the electrodes connected properly.
Alright?
Patrik: Right, right, right. Okay.
Stephanie: So you’re not gonna get a good reading. And that’s how she wanted to run a whole another 24-hours or whatever at that particular time. But now that she’s on the Fentanyl, I mean the um, Phenobarbital, then they have to, right Miranda?
Miranda: Okay, that was the thing I was looking for. I need to find a little bit to hold on.
Rebecca: And also they said they consider that as involuntary movement, too, with the shaking, because I saw when they took her off there, and they weaned her off a little bit, then they put her back on. So, I agree wholeheartedly at least to try the
previous one that you just said, first before they did that because I just see them at this moment in juncture, they just to hurry up and rush things up and they, you know, they was talking to Miranda. She is our mother and she is our sister as well, we need to come to a meeting, and stick together to agree upon the same thing and not let them take control and run this out of ICU.
Patrik: Mm-hmm (affirmative)-I agree on the one hand, they are keeping her deeply sedated. That’s the one thing. On the other hand, they’re already looking ahead to LTAC and trach and whatnot. Where in reality,
the first thing that needs to happen is they need to stop the Phenobarbital. And they need to assess. Can she wake up appropriately or not? That’s the next thing they need to assess.
Miranda: Mr. Patrik?
Patrik: Yup.
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Miranda: The Phenobarbital is 90 mg every eight hours.
Patrik: 90? Nine zero. 90 mg every eight hours.
Miranda: Yes. Nine zero.
Patrik: So that’s 270 mg in 24 hours. Just give me one second. That’s about 10 mg an hour roughly, 12 mg an hour. That’s a fair bit. So, that’s a large amount.
But they need to stop that.
Miranda: He’s saying that’s a very low amount. That’s what he is saying.
Patrik: That’s what they’re saying? What’s Carmen’s weight, roughly?
Miranda: Bigger than me. She’s like two-
Rebecca: She’s about 215.
Patrik: That’s, what is that, pounds? Because I going to make a bit-
Stephanie: 215 pounds, yes.
Patrik: Pounds okay, just give me one sec, just give me one sec. Yeah, that’s about nine, yeah, okay. Alright. That’s look, look, they, it’s probably with that weight it could be a little bit, yeah, it’s reasonable, but still.
The Phenobarbital from my experience is a last resort drug. You don’t want to, you know, any Phenobarbital that you give is too much, if you will.
Tonette: Stop it.
Stephanie: How about that.
Tonette: They can’t just stop it immediately, they have to get a different drug.
They have to get a different drug.
Patrik: Absolutely, and they should use, they should use Midazolam to begin with. Midazolam also known, I just quickly text this to you, Stephanie, so you can actually see that. You know, that can manage the seizures as well, and it wouldn’t take quite as long to assess somebody if they can wake up or not.
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Tonette: Mm-hmm (affirmative)-
Patrik: So then you’re talking about the ethics committee in the hospital. Look, an ethics committee looks good on paper, my experience shows if it’s a hospital ethics committee they will all back each other.
Stephanie: There you go.
Tonette: We’ve been through that with our mom.
Patrik: Right, right, so. I’m all for ethics committees, as long as they’re independent. The reality is if you are dealing with a hospital ethics committee, they will just back, all back each other, you know. You’ll have very limited input there.
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Stephanie: Okay, independent of the hospital or otherwise forget about it. Got it.
Patrik: That’s, you know, I really hope that I can give you a different perspective here, and I also hope that with that perspective you can get some outcomes, right?
I do believe a lot of what I’m doing is driven by my own ethics and by my own moral compass, if you will, right?
Am I running a business? Yes, I’m running a business, but I still feel like I’m one layer removed from the hospital. You know, I’ve tried to give you as much of an objective overview as I can.
With 20-years of ICU experience, right, I’ve seen all the ethics committees, and I know their full of shit, excuse my language, you know. It’s not worth your time.
Stephanie: No, got it.
The 1:1 consulting session will continue in next week’s episode.
